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PHARMACIST EXAMINATION AND LICENSURE APPLICATION INSTRUCTIONS

In order to be licensed in California as a pharmacist, you must pass the North American Pharmacist Licensure Examination (NAPLEX) and the California Practice Standards and Jurisprudence Examination for Pharmacists (CPJE). In order to be made eligible to sit for the NAPLEX and/or CPJE, the board must determine that you have met all the requirements.

IMPORTANT NAME AND IDENTIFICATION INFORMATION

1. Full Legal Name: It is very important that you apply under your full legal name. The board will make you eligible only under your full legal name of record with the board (not aliases). Your name of record with the board is the name you submit on your initial application (whether that is your pharmacy technician, intern pharmacist or pharmacist licensure examination application). If you have an intern pharmacist and/or pharmacy technician license and need to verify your name of record with the board prior to submitting your application, please visit the board’s Web site at www.pharmacy.ca.gov and select “Verify a License”. If your full name listed on your identifications does NOT match your name of record with the board, please submit a copy of your U.S. government issued photo identification AND U.S. government issued social security card OR national identity card with your application to update your name of record with the board.

2. Required Identifications to take the CPJE: At the testing site you will be required to present TWO of the

identifications listed below. One of the identifications MUST contain a photo. You cannot present two of the same type of identifications at the testing site. There are NO exceptions.

The two identifications that you choose to present at the testing site must match your full legal name of record with the board IDENTICALLY letter for letter (this includes middle name vs. middle initial). If your full name does not match identically on both identifications presented at the testing site, you will NOT be allowed to sit for the CPJE. Photocopies, temporary identifications and expired identifications will NOT be accepted. Please check your required identifications NOW to ensure both identifications match letter for letter. If your identifications do not match, the board encourages you to make the necessary changes NOW to ensure you have sufficient time to receive the correct identifications. Required Identifications: You cannot present two of the same type of identifications at the testing site. You must present TWO of the following identifications listed below at the testing site and ONE of the identifications MUST contain a photo. • US State, Commonwealth, or Territory issued driver’s license or identification card (may only present

one) • US government issued passport book or card (may only present one) • US social security card (cannot be laminated) • US military-issued identification

• National identity card

California State Board of Pharmacy BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS Phone (916) 574-7900 GOVERNOR EDMUND G. BROWN JR. Fax (916) 574-8618 www.pharmacy.ca.gov Fax (916) 327-6308

HOW LONG WILL IT TAKE TO PROCESS MY APPLICATION? ➢ Allow the board 30 days to process your application. ➢ You will be notified in writing if your application is incomplete or you will receive your eligibility letter. ➢ Please do not contact the board to check on the status of your application unless your application has

been on file for over 45 days. ➢ If your check has cleared your bank, the board has received your application. ➢ Once you have completed all the requirements for licensure (passing both NAPLEX and CPJE) and

your initial license application has been processed, you may verify your license at www.pharmacy.ca.gov. Select “Verify a License” and enter your name. It takes four to six weeks from the date the license is issued to receive it in the mail.

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WHAT MAKES AN APPLICATION COMPLETE Check the boxes below to be sure your application is complete before mailing it.

• If your application is not complete, you will receive a “Deficiency Letter” in the mail. • If you do not submit the required item(s), you will not be made eligible to sit for the pharmacist

examination(s) and your application may be withdrawn within one year. APPLICATION FEE $260: When you send your application, include a check or money order for $260

made payable to the Board of Pharmacy. The application fee is non-refundable.

PHARMACIST EXAMINATION AND LICENSURE APPLICATION: (17A-1): Complete the entire application.

AVOID COMMON MISTAKES • Look at your state issued driver’s license or state issued identification card prior to completing

the application. The name on each form listed below must be EXACTLY THE SAME as the name on your state issued driver’s license or state issued identification card. If you have a hyphenated name, two last names or two first names, you need to list your name on each of the following documents to match that of your state issued identification:

✓ Pharmacist Examination and Licensure Application, ✓ Request for Live Scan form or fingerprint cards, and ✓ Self-Query Report.

• Have you ever used a different name? List each prior name on the application under Previous Names. ✓ Did you have a maiden name, married name, former name, AKA? ✓ Have you ever used Jr., Sr., II, etc., with your name? ✓ If you do not list all of your previous names, the board may not locate, match or verify your

documents. ✓ Do you have a pharmacy technician or intern pharmacist license issued in another name? If

yes, submit a copy of your state issued identification for the board to update your name. • Do not leave anything blank: use “N/A” if a question doesn’t apply to you. • Do not let your school fill out Pages 1, 2, 3 and 4 of your application. • You must sign and date the application. No one else can sign it for you. Signatures must be original

and dated within 60 days of filing the application. No electronic, stamped, copies or faxed signatures will be accepted.

U.S. SOCIAL SECURITY NUMBER OR INDIVIDUAL TAXPAYER IDENTIFICATION NUMBER (ITIN): You are required to disclose your U.S. Social Security number or Individual Taxpayer Identification Number (ITIN). It must be included on the application and on the Self-Query Report.

PHOTO: Attach a NEW passport-style photo to page 1 of the application (glossy, color photo 2”x2”) taken within 60 days of filing the application. Do not submit the same picture submitted with your intern pharmacist application. DO NOT provide scanned images, Polaroid’s, or black-and-white photos.

MILITARY EXPEDITE: The board will expedite review of an application that meets one of the following criteria (A, B, or C).

A. Serving in the Military: Are you currently serving in the United States military?

✓ Attach a copy of your military identification.

B. Military Veteran: Have you ever served in the United States military?

✓ Attach a copy of your DD214 with your application.

C. Active Duty Military-Spouses or Partners: If your spouse or partner is an active duty member of the U.S. Armed Forces and you hold a current license in another state, please provide the

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following:

✓ Attach a copy of your current license in another state, district, or territory of the United States documenting the profession or vocation for which you seek license from the board.

✓ Attach a copy of the marriage certificate, or certified declaration/registration of domestic partnership, or other evidence of legal union.

✓ Attach a copy of your spouse or partner’s military orders establishing duty station in California.

MANDATORY EDUCATION: To qualify for a pharmacist license, you must submit one of the following to

document your education under A or B: A. Graduate of a School of Pharmacy - If you are a graduate from an ACPE accredited college of

pharmacy or a school of pharmacy recognized by the board, please request an official transcript to be sent directly to the board by your school. The official transcript must indicate your degree earned and date conferred.

OR B. Foreign Graduate of a School of Pharmacy - If you are a graduate of a foreign pharmacy school,

please submit a copy of your Foreign Pharmacy Graduate Examination Committee (FPGEC) certificate issued by the National Association of Boards of Pharmacy (NABP).

EXAMINATION SECURITY ACKNOWLEDGEMENT (17A-76): This document MUST be signed and dated

by the applicant within 60 days of filing the application and be submitted with your application.

PHARMACY INTERN HOURS: You must qualify under A or B. A. Graduated January 1, 2016 or After: Effective January 1, 2016, an applicant for the pharmacist

examination who has graduated on or after January 1, 2016 from an ACPE accredited college of pharmacy or school of pharmacy recognized by the board shall be deemed to have satisfied the pharmacy practice experience requirements and is not required to submit pharmacy intern affidavits documenting the 1,500 intern hours.

OR B. Graduated from a Foreign Pharmacy School or Graduated Prior to January 1, 2016: An applicant for

the pharmacist examination who has graduated from a foreign pharmacy school and submitted a copy of his/her FPGEC certificate or who has graduated from an ACPE accredited college of pharmacy or school of pharmacy recognized by the board prior to January 1, 2016, must complete and provide documentation of 1,500 hours of pharmacy practice experience as an intern pharmacist, unless licensed as a pharmacist for at least one year in another state.

A total of 1,500 intern hours is required but does not have to be obtained in one pharmacy location. Intern hours must be earned in the United States. You must submit Pharmacy Intern Hours Affidavit form(s) (17A-29) documenting you have experience in both a community and institutional pharmacy practice settings.

Documentation of Intern Hours

✓ Intern hours earned in California must be completed on the Pharmacy Intern Hours Affidavit form (17A-29) documenting 1,500 intern hours of pharmacy practice experience. The affidavit must have an original signature and be submitted with the application. Please submit a separate form for each pharmacy location.

✓ Intern pharmacy practice experience hours obtained in another state may be submitted to the board on one of the following forms:

• Verification of License in Another State form (17A-16). If you hold an intern license in another state this form must be submitted verifying the status of your intern license. If the licensing agency in the state where the intern hours were obtained will transfer your intern hours to California, you may request that licensing agency to certify the number of intern hours on this form. Not all state licensing agencies will transfer intern hours to another state. Please contact

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the state licensing agency directly to verify if they will transfer your intern hours to California. OR

• If the state licensing agency will not transfer your intern hours to California, you are still required to submit proof of your intern hours on the Pharmacy Intern Hours Affidavit form (17A-29) documenting 1,500 hours of pharmacy practice experience as an intern pharmacist. Documentation of intern hours obtained in another state does not replace a license verification from the other state submitted on the Verification of License in Another State form (17A-16).

VERIFICATION OF LICENSE IN ANOTHER STATE: If you currently hold or previously held a license in another state as a pharmacist, intern pharmacist, pharmacy technician, designated representative, designated representative-3PL and/or other health care professional, you must request each state agency to verify your license by completing the required Verification of License in Another State form (17A-16). You need to submit only one form 17A-16 per state.

• If another state verifies that you have been licensed as a pharmacist for at least one year, you are not required to submit documentation of your intern hours.

SELF-QUERY REPORT: Include a sealed, original Self-Query Report from the National Practitioner Data

Bank (NPDB). It must be dated within 60 days of filing the application. • Self-Query Reports that have been opened will not be accepted. • The name on your Self-Query Report must be EXACTLY THE SAME as the name on your

application. • To request a Self-Query Report, go to the NPDB’s Web site at http://www.npdb.hrsa.gov/ or the

direct link is https://www.npdb.hrsa.gov/ext/selfquery/SQHome.jsp • NPDB’s contact number (800) 767-6732 or TDD (703) 802-9395. Their Web site has a fact

sheet and answers to frequently asked questions. The board is not able to assist you with requesting the Self-Query Report. For help, contact the NPDB directly.

• You must pay the fee directly to NPDB. The fee is $5. • You must submit a new Self- Query Report even if one was submitted with a previous

application.

FINGERPRINTS: • California residents must use Live Scan. Non-residents can visit California to complete a Live

Scan or must submit professionally rolled fingerprints on cards supplied by the board. • DO NOT complete the Live Scan service or fingerprint cards until you are ready to send in your

application. • You must submit a copy of your Live Scan receipt or two rolled fingerprint cards with your

application • Each application requires you to complete a new Live Scan or submit new fingerprint cards. • The Live Scan site may charge a processing fee. • The board will accept fingerprint responses only from the California Department of Justice

(DOJ) and Federal Bureau of Investigation (FBI).

Please complete and attach ONE of the following A or B:

A. California Resident: Attach a copy of your completed Live Scan receipt. The receipt shows you completed the Live Scan.

• California residents must use Live Scan only. • To find a Live Scan location, go to https://oag.ca.gov/fingerprints/locations • Live Scan operators can make mistakes. Be proactive; make sure everything the operator keys

in to their computer is correct before the operator transmits your prints to the Department of Justice.

Make sure the following information is correct when you complete your Live Scan: • Type of License/Certification/Permit or Working Title: Pharmacist – Section 4050 • Full Name: Must be EXACTLY THE SAME as the name on your state issued driver’s license or

state issued identification card. (Jr., II, etc., must be included). It must also be EXACTLY THE SAME as the name on your application and your Self-Query Report.

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• Date of Birth: Must be correct. • Social Security Number: Must be included and be correct, unless you have an ITIN. If you

have an ITIN, enter this number in the SSN field. • Level of Service: Must include both DOJ and FBI.

B. Non-California Resident: You may visit California and complete Live Scan, if you cannot then you

must submit two rolled fingerprint cards with your application. • You must use fingerprint cards from the Board of Pharmacy. • Request fingerprint cards through the board’s online services at

https://www.dca.ca.gov/webapps/pharmacy/pubs_request.php or email rxforms@dca.ca.gov. • Fee: Include fingerprint card processing fee of $49 ($32 DOJ and $17 FBI), made payable to

the Board of Pharmacy. • You can send one check or money order for both the application processing fee and fingerprint

processing fee. • Print legibly or type your personal information on the fingerprint cards. If your personal

information is not legible and DOJ enters your information incorrectly, you will be responsible to submit new fingerprint cards and pay the $49 fingerprint processing fee again.

• Fingerprints must be taken by a person professionally trained to roll prints. • Fingerprint clearances from cards take about six weeks longer than Live Scan. • Poor quality prints will be rejected and will cause delay because new fingerprint cards will be

required.

EXAMINATION INFORMATION CPJE: The CPJE is the California state pharmacist examination. You cannot schedule this examination until the board has made you eligible. Once you receive the board’s eligibility letter, please allow up to two weeks for PSI to mail you a Candidate Information Bulletin. The outside cover of the handbook is your “Notice of Eligibility” and you will use the information in this handbook to contact PSI to schedule the CPJE. The board encourages you to read the entire handbook for important information relating to the examination process. The CPJE is administered by PSI. There is an administration fee of $33 that you will pay directly to PSI for the test administration services before you will be able to schedule your test date for the CPJE. DO NOT send this fee to the Board of Pharmacy.

Periodically, the board performs quality assurance assessments of the CPJE. These assessments delay the release time of the CPJE results. If an assessment is underway, information will be posted on the board’s Web site at http://www.pharmacy.ca.gov/ informing applicants of the assessment and delay in receiving results. The board makes every effort to complete the assessment as quickly as possible. NAPLEX: The NAPLEX is the national pharmacist examination and you may take this examination in California as your primary state or in another state as your primary state. You may take the NAPLEX after you apply to your primary state and have been made eligible by that state. Visit the National Association of Boards of Pharmacy (NABP) Web site at http://www.nabp.net/ for information on how to register for the NAPLEX. Download the NAPLEX/MPJE Bulletin from the NABP Web site. You must register on-line and pay the NAPLEX fee DIRECTLY to the NABP.

If California is your Primary State:

You may register with NABP simultaneously when submitting your pharmacist examination and licensure application to the board or after the board has made you eligible to take the pharmacist examination. If you choose to register for the NAPLEX after the board has made you eligible for the examination, please allow two weeks for the board to approve your eligibility with the NABP. Once the board has approved your eligibility with the NABP, the NABP will mail you an Authorization To Test (ATT) letter. At this point, you will be able to schedule the location, date and time for your NAPLEX exam. Requirements and specifications for the NAPLEX are available in the NAPLEX/MPJE Bulletin. Additionally, there is a preNAPLEX test you may take to prepare you for the NAPLEX. If you already have taken and

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passed the NAPLEX, information on how to request a score transfer through the NABP is on their Web site.

If another state is your Primary State: Licensure Transfer - If another state is your primary state for the NAPLEX and you are licensed in another state you will need to request a licensure transfer through the NABP. Please visit the NABP Web site at http://www.nabp.net/ for the instructions. Once you have completed the licensure transfer process with the NABP, please mail the licensure transfer packet directly to the board. In order for the board to receive your NAPLEX score from the NABP, you must complete and submit the NABP licensure transfer packet to the board. The board does not require a fee. Fees are paid directly to the NABP.

OR Score Transfer – At the time of sitting for the NAPLEX or within 90 days of sitting for the NAPLEX you can designate California as a score transfer state. If you are eligible to request a score transfer with NABP, please email the board at intern-examstatus@dca.ca.gov once the NABP has been processed your score transfer request. The board is cannot retrieve your NAPLEX score until the NABP has processed your score transfer request.

ADDITIONAL EXAMINATION INFORMATION • The NAPLEX and CPJE examinations are administered via computer. • Testing centers for both examinations are available nationwide and, in most cases, are open six days a

week, excluding holidays. • You may take the NAPLEX and CPJE in any order. You will have one year to sit for the examination(s)

from the date of the board’s eligibility letter. Examination results for both exams will be mailed to you by the board. Please allow the board 30 days to process examination results. When the board is conducting a CPJE quality assurance assessment this time may be increased.

• If you do not pass either examination, you will need to submit a Retake Application (17A-1A) to the board. You will not be allowed to sit for either examination until it has been 90 days from the date of your last examination.

• The NAPLEX and CPJE are separate examinations. If you fail one examination and pass the other, you must reapply and take only the examination that you did not pass. If you fail the NAPLEX, you must reapply with the NABP and pay the necessary fees in order to retake the exam as well as submit a Retake Application (17A-1A) to the board. If you fail the CPJE, you must reapply with the board and pay the required CPJE fee.

• If it has been over one year since you the board has made you eligible to sit for the examination(s), you must submit a new pharmacist examination and licensure application (17A-1).

SPECIAL ACCOMMODATIONS The California State Board of Pharmacy recognizes its responsibilities under Title II of the Americans with Disabilities Act to provide reasonable accommodations, including auxiliary aids to qualified examination candidates with disabilities. However, the board will not provide an accommodation which fundamentally alters the measurement of the knowledge or skills the examination is intended to test, compromises examination security, or creates an undue financial and administrative burden. A candidate who seeks an accommodation has the responsibility to make the request to the board and to provide reasonable documentation of the need for accommodation at least 90 days before he or she sits for the examination. The information supplied to substantiate a candidate's request for an accommodation will be kept confidential to the extent allowed by law. Information on this process is available from the board’s Web site.

PHARMACIST EXAMINATION AND LICENSURE APPLICATION All information requested in this application are mandatory. Failure to provide any information will result in the application being considered incomplete. If your names on your required identifications as specified on page 1 of the application instructions do not match identically the testing site will NOT allow you to sit for the CPJE. Photocopies, temporary identifications and expired identifications will NOT be accepted. Please check your required identifications NOW to ensure they all match letter for letter. If your identifications do not match, the board encourages you to make the necessary changes now to ensure you have sufficient time to receive the correct identifications. Read the application instructions before you complete the application. All questions on this application must be answered by the applicant. The applicant must sign and date the application. If not applicable, indicate N/A. Attach additional sheets of paper, if necessary. Military Expedite MILITARY (Are you serving in the United States military?) 

    VETERAN (Have you ever served in the United States military?) Applicant Information - Please Type or Print ACTIVE DUTY MILITARY-Spouse or Partner Full Legal Name: Last Name: First Name: Middle Name:

Previous Names (AKA, Maiden Name, Alias, etc):

Official Mailing/Public Address of Record (Street Address, PO Box #, etc):

City: State: Zip Code:

Residence Address (if different from above):

City: State: Zip Code:

Home#: ( ) Cell#: ( ) Work#: ( )

Driver’s License #: State: Email Address:

Date of Birth (Month/Day/Year): US Social Security # or ITIN: Pharmacist Education

Name(s) of University, College, or School of Pharmacy Country

Date of Graduation

Degree

License Information: List all state(s) where you are or have previously been licensed as a pharmacist, intern pharmacist, pharmacy technician, designated representative, and/or other healthcare professional license, including California. All licenses held outside of California must be verified on the Verification of Licensure in Another State (form 17A-16).

State License Type and

Number Active or Inactive

Issued Date Expiration Date

Self-Query Report from the National Practitioner Data Bank (NPDB)

Attached is the original sealed envelope containing my Self-Query Report from the NPDB. (This must be submitted with your application.)

THIS SECTION IS FOR BOARD USE ONLY

App Fee

Enf. Check:

Photo:

Exam Security:

Transcript:

FPGEC:

SQ:

Qualify Code: _______

School Code: _______

Intern Hours: _______

EXAM HISTORY CASHIERING ONLY Date NAPLEX CPJE APPLICATION FEE

Receipt #:

Date Cashiered:

Amount:

Licensure Verification

FP Card/Fees: DOJ Date: _________ LS: FBI Date: _________

Remedial Education (Transcripts):

School:

1

California State Board of Pharmacy BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS Phone (916) 574-7900 GOVERNOR EDMUND G. BROWN JR. Fax (916) 574-8618 www.pharmacy.ca.gov

TAPE A COLOR PASSPORT

STYLE 2”X2” PHOTO TAKEN

WITHIN

60 DAYS OF THE FILING OF

THIS APPLICATION

NO POLAROID

OR SCANNED IMAGES

PHOTO MUST BE ON PHOTO

QUALITY PAPER

ALL APPLICANTS MUST ANSWER THE FOLLOWING QUESTIONS (Attach additional sheets of paper if necessary) 1. Have you obtained a minimum of 900 hours of pharmacy practice experience in a pharmacy as an intern

pharmacist or pharmacist as required by Title 16 California Code of Regulations section 1728? If “no”, please attach an explanation listing the experience you have obtained.

Yes No

2. Have you completed experience in both community and institutional pharmacy settings as required by Title 16 California Code of Regulations section 1728?

If “no”, please attach an explanation as to the reason you have not completed this experience.

Yes No

3. Have you taken the California pharmacist licensure exam before January 1, 2004 (when it was a multiple-choice and short answer/essay exam)? If “yes,” provide all exam date(s). __________________________________________

Yes No

4. Have you taken the California Practice Standards and Jurisprudence Examination for Pharmacists (CPJE) before?

If “yes,” provide all dates. _____________________________

Yes No

5. Have you passed the CPJE? If “yes,” provide the exam date. ________________________

Yes No

6. Have you taken the North American Pharmacist Licensure Examination (NAPLEX) after January 1, 2004? If “yes,” provide all dates. _____________________________

Yes No

7. Have you passed the NAPLEX after January 1, 2004? If “yes,” provide the exam date. ________________________

Yes No

8. Have you ever applied for and not taken the CPJE and/or NAPLEX? If “yes,” provide eligibility date(s). __________________________

Yes No

9. Have you ever been licensed as a pharmacist in California? If “yes,” provide California pharmacist license number. ________________________

Yes No

10. Have you ever been expelled from a pharmacist licensure exam administered in this state or any other state? If “yes,” provide the date and state. ___________________________________

Yes No

11. Have you previously taken a pharmacist licensure exam which was not graded or had exam results withheld on grounds of dishonest conduct during an examination in this state or any other state? If “yes,” provide the date and state. _________________________________________

Yes No

12. Do you have a mental illness or physical illness that in any way impairs or limits your ability to practice your profession with reasonable skill and safety without exposing others to significant health or safety risks?

If “yes,” attach a statement of explanation. If “no,” proceed to #13.

Yes No

Are the limitations caused by your mental illness or physical illness reduced or improved because you receive ongoing treatment or participate in a monitoring program? Yes No If “yes,” attach a statement of explanation. If you do receive ongoing treatment or participate in a monitoring program, the board will make an individualized assessment of the nature, severity and duration of the risks associated with an ongoing medical condition to determine whether an unrestricted license should be issued, whether conditions should be imposed, or to determine if you are not eligible for licensure.

13. Do you currently engage or have you previously engaged in the illegal use of controlled substances? If “yes,” are you currently participating in a supervised substance abuse program or professional assistance

program which monitors you in order to assure that you are not engaging in the illegal use of controlled substances? Attach a statement of explanation. Yes No

If “yes,” have you participated in a substance abuse program in the past five years? Yes No Attach a statement of explanation.

Yes No

14. Have you ever had an application for intern pharmacist, pharmacist, pharmacy technician and/or designated representative license denied in this state or any other state? If “yes,” attach a statement of explanation to include circumstances, type of action, date of action and type of application involved.

Yes No

15. Have you ever had an intern pharmacist, pharmacist, pharmacy technician, designated representative, and/or any other professional or vocational license or registration suspended, revoked, placed on probation or had other disciplinary action taken by this or any other government authority in California or any other state? If “yes,” attach a statement of explanation to include circumstances, type of action, date of action and type of license, registration or license involved.

Yes No

16. Are you currently or have you previously been listed as a corporate officer, partner, owner, manager, member, administrator or medical director on a license to conduct a pharmacy, wholesaler, third-party logistics provider or any other entity licensed in the state or any other state? If yes, provide company name, type of license, license number and state where licensed.

Yes No

17. Have you ever had a pharmacy, wholesaler, and/ or third-party logistics provider application and/or a professional license denied, suspended, revoked, placed on probation or had other disciplinary action taken by this or any other government authority in California or any other state?

If “yes,” provide the name of company, type of license, type of action, year of action and state. _________________________________________________________________________________

Yes No

18. Have you ever been convicted of, or pleaded guilty or nolo contender/no contest to, any crime, in any state, the United States or its territories, a military court, or any foreign country? Include any felony or misdemeanor offense, and any infraction involving drugs or alcohol with a fine of $500 or more. You must disclose a conviction even if it was: (1) later dismissed or expunged pursuant to Penal Code section 1203.4 et seq., or an equivalent release from penalties and disabilities provision from a non-California jurisdiction, or (2) later dismissed or expunged pursuant to Penal Code section 1210 et seq., or an equivalent post-conviction drug treatment diversion dismissal provision from a non-California jurisdiction. Failure to answer truthfully and completely may result in the denial of your application.

NOTE: You may answer “NO” regarding, and need not disclose, any of the following: (1) criminal matters adjudicated in juvenile court; (2) criminal charges dismissed or expunged pursuant to Penal Code section 1000.4 or an equivalent deferred entry of judgment provision from a non-California jurisdiction; (3) convictions more than two years old on the date you submit your application for violations of California Health and Safety Code section 11357, subdivisions (b), (c), (d), or (e), or California Health and Safety Code section 11360, subdivision (b); and (4) infractions or traffic violations with a fine of less than $500 that do not involve drugs or alcohol.

You may wish to provide the following information in order to assist in the processing of your application: descriptive explanation of the circumstances surrounding the conviction (i.e. dates and location of incident and all circumstances surrounding the incident.) If documents were purged by the arresting agency and/or court, a letter of explanation from these agencies is required.

Failure to disclose a disciplinary action or conviction may result in the license being denied or revoked

for falsifying the application. Attach additional sheets if necessary.

Arrest Date Conviction Date Violation(s) Case # Court of Jurisdiction (Full Name and Address)

Yes No

APPLICANT AFFIDAVIT

You must provide a written explanation for all affirmative answers. Failure to do so will result in this application being deemed incomplete. Falsification of the information on this application may constitute grounds for denial or revocation of the license. Mandatory Submission. Submission of the requested information is mandatory. The California State Board of Pharmacy cannot consider your application for licensure or renewal unless you provide all of the requested information. You must answer all information on this application. Failure to provide any of the requested information may result in the application being rejected as incomplete. Collection and Use of Personal Information. The California State Board of Pharmacy of the Department of Consumer Affairs collects the personal information requested on this form pursuant to Business and Professions Code sections 4200, 4208 and 4209 and Title 16 California Code of Regulations sections 1725 and 1728. The California State Board of Pharmacy uses this information to identify and evaluate applicants for licensure, issue and renew licenses, and enforce licensing standards set by law and regulation. Access to Personal Information. You have the right to review the records maintained by the California State Board of Pharmacy that contain your personal information, as permitted by the Information Practices Act, unless confidential and exempt by Civil Code Section 1798.40. The official responsible for maintaining records is the Executive Officer at the board’s address listed on the application. Possible Disclosure of Personal Information. We make every effort to protect the personal information you provide us. The information you provide, however, may be disclosed under the following circumstances: • In response to a Public Records Act request (Government Code Section 6250 and following), as allowed by the Information Practices Act (Civil

Code Section 1798 and following); • To another government agency as required by state or federal law; or • In response to a court or administrative order, a subpoena, or a search warrant.

Once you are licensed with the board, the address of record you enter on this application is considered public information pursuant to the Information Practices Act (Civil Code section 1798 et seq.) and the Public Records Act (Government Code Section 6250 et seq.) and will be placed on the Internet. This is where the board will mail all correspondence. If you do not wish your residence address to be available to the public, you may provide a post office box number or a personal mail box (PMB). However, if your address of record is not your residence address, you must also provide your residence address to the board, in which case your residence will not be available to the public.

Disclosure of your U.S. Social Security number or Individual Taxpayer Identification Number (ITIN) is mandatory. Section 30 of the Business and Professions Code, Section 17520 of the Family Code, and Public Law 94-455 (42 USC § 405(c)(2)(C)) authorize collection of your social security number or individual taxpayer identification number. Your social security number or individual taxpayer identification number will be used exclusively for tax enforcement purposes, for purposes of compliance with any judgment or order for child or family support in accordance with section 17520 of the Family Law Code, or for verification of license or examination status by a licensing or examination entity which utilizes a

3

national examination and where licensure is reciprocal with the requesting state. If you fail to disclose your social security account number or individual taxpayer identification number, your application will not be processed and you may be reported to the Franchise Tax Board, which may assess a $100 penalty against you. NOTICE: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share taxpayer information with the board. You are obligated to pay your state tax obligation. This application may be denied or your license may be suspended if your state tax obligation is not paid.

MANDATORY REPORTER Under California law, each person licensed by the Board of Pharmacy is a “mandated reporter” for both child and elder abuse or neglect purposes. California Penal Code Section 11166 and Welfare and Institutions Code Section 15630 require that all mandated reporters make a report to an agency specified in Penal Code Section 11165.9 and Welfare and Institutions Code Section 15630(b)(1) [generally law enforcement, state, and/or county adult protective services agencies, etc.] whenever the mandated reporter, in his or her professional capacity or within the scope of his or her employment, has knowledge of or observes a child, elder and/or dependent adult whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or elder abuse or neglect. The mandated reporter must contact by telephone immediately or as soon as possible, to make a report to the appropriate agency(ies) or as soon as is practicably possible. The mandated reporter must prepare and send a written report thereof within two working days or 36 hours of receiving the information concerning the incident. Failure to comply with the requirements of Section 11166 and Section 15630 is a misdemeanor, punishable by up to six months in a county jail, by a fine of one thousand dollars ($1,000), or by both that imprisonment and fine. For further details about these requirements, consult Penal Code Section 11164 and Welfare and Institutions Code Section 15630, and subsequent sections.

APPLICANT AFFIDAVIT (must be signed and dated by the applicant)

I, , hereby attest to the fact that I am the applicant (Print full legal name) whose signature appears below. I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy of all statements, answers and representations made in this application, including all supplementary statements. I understand that my application may be denied, or any license disciplined, for fraud or misrepresentation. Original Signature of Applicant (signed and dated within 60 days of filing the application) Date

17A-1 (11/2015) Rev: 17A-1 RPH Application (11.2015)

4

17A-76 (Rev. 7.14)

California State Board of Pharmacy BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS Phone (916) 574-7900 GOVERNOR EDMUND G. BROWN JR. Fax (916) 574-8618 www.pharmacy.ca.gov

EXAMINATION SECURITY ACKNOWLEDGEMENT

The California State Board of Pharmacy is committed to maintaining the security and the confidentiality of all examination materials during every phase of development and administration. The board strictly enforces examination security and will prosecute any individual who has been determined to be in violation of statutes pertaining to examination security. There are a number of laws and regulations that provide for the security of the state’s occupational exams and exam processes, such as the board’s licensure exams. These include Business and Professions Code sections 123, 496 and 584, as well as Civil Code section 980 and California Code of Regulation section 1723.1. For example, it is a misdemeanor for anyone to compromise or attempt to compromise a licensing examination. Persons convicted of this crime are personally liable for up to $10,000 in damages and the costs of litigation, in addition to other penalties. The board may also deny or revoke a license on grounds that the applicant has compromised or attempted to compromise a licensing examination. Examples of compromising a licensing examination include removing examination materials from a test site without authorization; aiding by any means the reproduction of any portion of the actual examination; paying or using professional or paid examination takers to reconstruct any portion of the examination; and selling, distributing, buying, receiving or having unauthorized possession of any portion of a future, current or previously administered licensing examination. For example, an individual who memorizes a test item with or without intent to provide this information to the provider of a review course is compromising the exam. California law provides that no person shall violate the security of a licensing examination. Examples include impersonating someone, attempting to impersonate someone, or soliciting the impersonation of someone. Using notes and looking at another candidate’s examination materials are two examples of dishonest conduct. Any form of dishonest conduct or cheating, including using prohibited aids, giving or receiving assistance, or communicating with others, may result in the voiding of your examination results and/or dismissal from the examination site. Failure to follow the instructions of the testing center administrators, whether or not dishonest conduct or cheating is involved, may also result in the disqualification of your examination results and/or dismissal from the examination site. The test site administrators reserve the right to videotape any examination session. By signing this acknowledgement, you are affirming that you fully understand the foregoing. A violation of these laws may result in your disqualification as a candidate and could result in an administrative action and/or denial of a pharmacist or intern pharmacist license by the board, plus other penalties. I hereby acknowledge that I have read the above statement. ____________________________________________ Name of Candidate Printed ____________________________________________ ______________ Original Signature of Candidate Date

Pharmacy Intern Hours Affidavit

Completed by the Supervising Pharmacist or Pharmacist-in-Charge An applicant for the pharmacist examination who has graduated from an ACPE accredited college of pharmacy or school of pharmacy recognized by the board prior to January 1, 2016 or graduated from a foreign pharmacy school and submitted a copy of his/her FPGEC certificate must complete and provide documentation of 1,500 hours of pharmacy practice experience as an intern pharmacist. A total of 1,500 intern hours is required but does not have to be obtained in one pharmacy location. Intern hours must be earned in the United States. This affidavit must be completed by the supervising pharmacist or pharmacist-in-charge at the pharmacy while the intern pharmacist obtained the experience. The affidavit cannot be completed prior to the last day worked. Original affidavits are required. Photocopies or faxes will not be accepted. Any changes must be initialed by the supervising pharmacist or pharmacist-in-charge. All dates must include the month, day, and year in order for the form to be accepted (present or current will not be accepted).

A. TO BE COMPLETED BY APPLICANT: (Please print or type) Name of Applicant:

Intern Number Date Issued Expiration Date

Residence Address: Number and Street City State Zip Code

B. TO BE COMPLETED BY THE SUPERVISING PHARMACIST OR PHARMACIST-IN-CHARGE Name of Applicant:

Name of Pharmacy Pharmacy License Number

Address of Pharmacy Number and Street City State Zip Code

Name of Supervising Pharmacist or Pharmacist-in-charge

Pharmacist Contact Phone Number ( )

Pharmacist License Number

State Licensed

The applicant listed under section “B” was employed or volunteered as an intern pharmacist during the time set forth as follows:

From: _______ /______ / _______ To: ________ / _______ / __________ (month/day/year) (month/day/year)

A total of 1,500 intern hours is required but does not have to be obtained in one pharmacy location. Please indicate below the number of hours the intern pharmacist obtained while under your supervision. ___________ Number of hours of pharmacy practice experience obtained in a pharmacy. ___________ Number of hours of pharmacy practice experience substantially related to the practice of Pharmacy. NOTE: A maximum of 600 hours may be granted at the discretion of the board. I certify under penalty of perjury under the laws of the State of California that all statements given under section “B” of this form herein are true, and that to the best of my knowledge the experience thus gained by this applicant meets the pharmacy practice experience obtained in a pharmacy as required by law. I further certify that my license is not revoked, suspended, or on probation in any state in which I am now or have been registered. Original Pharmacist’s Signature Date 17A-29 (1.2016)

California State Board of Pharmacy BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS

Phone (916) 574-7900 GOVERNOR EDMUND G. BROWN JR. Fax (916) 574-8618 www.pharmacy.ca.gov

17A-16 (8/2015)

VERIFICATION OF LICENSE IN ANOTHER STATE

This form must be completed by the licensing agency in each state you hold or held a pharmacist, intern pharmacist, pharmacy technician, designated representative, designated representative-3PL license and or another healthcare professional license even if the license is no longer current or active. Please return the state-verified form with your application for each license type. Photocopies or faxes will not be accepted. Intern hours and licensure earned in another state may be certified by the licensing agency in each state you earned your intern hours or license on this form. A. TO BE COMPLETED BY APPLICANT (Please print or type) Name of Applicant:

Telephone Number:

Residence Address: Number and Street City State Zip Code

Type of License: License Number: Date Issued:

Expiration Date:

The person listed above has applied for a pharmacist license in California. Before further consideration is given to this application, the California State Board of Pharmacy would appreciate your assistance in completing the information requested below. Upon completion of this form, please return it to the applicant for submission with the application. B. TO BE COMPLETED BY THE STATE LICENSING BOARD OR AGENCY VERIFYING LICENSURE Licensee’s Full Name: Licensure Verification Provided

by the State of:

Type of License Issued: License Number: Date License Issued : Expiration Date: Intern Hours Earned in this State under this Intern License:

License Status (please check one box):

Active Inactive Other If other, please explain: _____________________________________

Has this agency taken any disciplinary action against this license? Yes No If disciplinary action has been taken against this licensee, please directly provide this office with the accusation/proposed charges and decision/final order regarding the action.

I hereby certify the information listed in Section “B” above is true and correct. ___________________________________________ Printed Name

Signature

Title of Authorized Official

Date

California State Board of Pharmacy BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY

1625 N. Market Blvd, Suite N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS Phone (916) 574-7900 Fax (916) 574-8618 GOVERNOR EDMUND G. BROWN JR. www.pharmacy.ca.gov

Board Seal

California State Board of Pharmacy STATE AND CONSUMER SERVICES AGENCY 1625 N. Market Blvd, N219, Sacramento, CA 95834 DEPARTMENT OF CONSUMER AFFAIRS Phone: (916) 574-7900 GOVERNOR EDMUND G. BROWN JR. Fax: (916) 574-8618 www.pharmacy.ca.gov

Business and Professions Code section 4200. Pharmacist License Requirements: Age; Education; Experience; Examination; Proof of Qualifications; Fees  (a) The board may license as a pharmacist an applicant who meets all the following requirements:  (1) Is at least 18 years of age.  (2) (A) Has graduated from a college of pharmacy or department of pharmacy of a university recognized by the board; or  (B) If the applicant graduated from a foreign pharmacy school, the foreign‐educated applicant has been certified by the Foreign Pharmacy Graduate Examination Committee.  (3) Has completed at least 150 semester units of collegiate study in the United States, or the equivalent thereof in a foreign country. No less than 90 of those semester units shall have been completed while in resident attendance at a school or college of pharmacy.  (4) Has earned at least a baccalaureate degree in a course of study devoted to the practice of pharmacy.  (5) Has completed 1,500 hours of pharmacy practice experience or the equivalent in accordance with Section 4209.  (6) Has passed a written and practical examination given by the board prior to December 31, 2003, or has passed the North American Pharmacist Licensure Examination and the California Practice Standards and Jurisprudence Examination for Pharmacists on or after January 1, 2004.  (b) Proof of the qualifications of an applicant for licensure as a pharmacist, shall be made to the satisfaction of the board and shall be substantiated by affidavits or other evidence as may be required by the board.  (c) Each person, upon application for licensure as a pharmacist under this chapter, shall pay to the executive officer of the board, the fees provided by this chapter. The fees shall be compensation to the board for investigation or examination of the applicant.  

 Effective January 1, 2016, Section 4209 of the Business and Professions Code is amended to read:  (a) (1) An intern pharmacist shall complete 1,500 hours of pharmacy practice experience before applying for the pharmacist licensure examination.  (2) This pharmacy practice experience shall comply with the Standards of Curriculum established by the Accreditation Council for Pharmacy Education (ACPE) or with regulations adopted by the board.  (3) This pharmacy practice experience shall include 900 hours of pharmacy practice experience in a pharmacy as a pharmacist and shall include pharmacy practice experience in both a community and institutional pharmacy practice setting.  (b) An intern pharmacist shall submit proof of his or her pharmacy practice experience on board‐approved affidavits, or another form specified by the board, which shall be certified under penalty of perjury by a pharmacist under whose supervision such the experience was obtained or by the pharmacist‐in‐charge at the pharmacy while the pharmacist intern obtained the experience. Intern hours Pharmacy practice experience earned in another state may be certified by the licensing agency of that state to document proof of those hours.  (c) An applicant for the examination who has been licensed as a pharmacist in any state for at least one year, as certified by the licensing agency of that state, may submit this certification to satisfy the required 1,500 hours of intern pharmacy practice experience, provided that the applicant has obtained a minimum of 900 hours of pharmacy practice experience in a pharmacy as a pharmacist. pharmacist and has pharmacy practice experience in both a community and institutional pharmacy practice setting. Certification of an applicant’s licensure in another state shall be submitted in writing and signed, under oath, by a duly authorized official of the state in which the license is held.  (d) An applicant for the examination who has graduated after January 1, 2016, from an ACPE accredited college of pharmacy or school of pharmacy recognized by the board shall be deemed to have satisfied the pharmacy practice experience requirements specified in subdivisions (a) and (b).   Title 16, California Code of Regulations section 1728. Requirements for Examination.  (a) Prior to receiving authorization from the board to take the pharmacist licensure examinations required by section 4200 of the Business and Professions Code, applicants shall submit to the board the following:  (1) Proof of 1500 hours of pharmacy practice experience that meets the following requirements:  (A) A minimum of 900 hours of pharmacy practice experience obtained in a pharmacy.  

(B) A maximum of 600 hours of pharmacy practice experience may be granted at the discretion of the board for other experience substantially related to the practice of pharmacy.  (C) Experience in both community pharmacy and institutional pharmacy practice settings.  (D) Pharmacy practice experience that satisfies the requirements for both introductory and advanced pharmacy practice experiences established by the Accreditation Council for Pharmacy Education.  (2) Satisfactory proof that the applicant graduated from a recognized school of pharmacy.  (3) Fingerprints to obtain criminal history information from both the Department of Justice and the United States Federal Bureau of Investigation pursuant to Business and Professions Code section 144.  (4) A signed copy of the examination security acknowledgment.  (b) Applicants who hold or held a pharmacist license in another state shall provide a current license verification from each state in which the applicant holds or held a pharmacist license prior to being authorized by the boar to take the examinations.  (c) Applicants who graduated from a foreign school of pharmacy shall provide the board with satisfactory proof of certification by the Foreign Pharmacy Graduate Examination Committee prior to being authorized by the board to take the examinations.  Authority cited: Sections 851, and 4005, Business and Professions Code. Reference: Sections 144, 851, and 4200, Business and Professions Code.   

Business and Professions Code section 4200.1 Multiple Failures of License Examination; Additional 

Education Requirements  (a) Notwithstanding Section 135, an applicant may take the North American Pharmacist Licensure Examination four times, and may take the California Practice Standards and Jurisprudence Examination for Pharmacists four times.  (b) Notwithstanding Section 135, an applicant may take the North American Pharmacist Licensure Examination and the California Practice Standards and Jurisprudence Examination for Pharmacists four additional times each if he or she successfully completes, at minimum, 16 additional semester units of education in pharmacy as approved by the board.  (c) The applicant shall comply with the requirements of Section 4200 for each application for reexamination made pursuant to subdivision (b).  (d) An applicant may use the same coursework to satisfy the additional educational requirement for each examination under subdivision (b), if the coursework was completed within 12 months of the date of his or her application for reexamination.  (e) For purposes of this section, the board shall treat each failing score on the pharmacist licensure examination administered by the board prior to January 1, 2004, as a failing score on both the North American Pharmacist Licensure Examination and the California Practice Standards and Jurisprudence Examination for Pharmacists.   

Title 16, California Code of Regulations section 1725. Acceptable Pharmacy Coursework for Examination 

Candidates with Four Failed Attempts.  (a) Coursework that meets the requirements of section 4200.1 of the Business and Professions Code is any pharmacy coursework offered by a recognized school of pharmacy.  (b) A final examination must be a part of the course of study.  (c) When a candidate applies for reexamination after four failed attempts, he or she shall furnish evidence of successful completion of at least 16 semester units or the equivalent of pharmacy coursework. Evidence of successful completion must be posted on a transcript from the pharmacy school sent directly to the board.  Authority cited: Section 4005, Business and Professions Code. Reference: Section 4200.1, Business and Professions Code.        Rev 1.2016 

INSTRUCTIONS FOR COMPLETING A "REQUEST FOR LIVE SCAN SERVICE" FORM

California Residents The following instructions are provided to assist you in completing this form accurately. Please follow all instructions carefully and print clearly.

NOTE TO LICENSEE and LIVE SCAN OPERATOR: The name, date of birth and US Social Security Number (SSN) or Individual Taxpayer Identification Number (ITIN) must be entered in at the time of the Live Scan transmission in order for the results to be accepted by the Board of Pharmacy. If the name, date of birth or SSN or ITIN is not entered at the time of Live Scan transmission, the licensee may have to have a new Live Scan transmission completed.

Type of License/Certification or Permit or Working Title: The Live Scan operator must enter in your type of license. Please have the Live Scan operator enter in in the Type of License listed on the Live Scan Form.

Applicant Information: Name: Enter your last name, first name and middle name. Do not use initials or name abbreviations. Your legal name must be on file with the board. If your name has changed you are required to notify the board within 30 days of the change. Other Name (AKA): Enter all other names you have used, including your maiden name. Date of Birth: (month/day/year). SEX: Mark the appropriate gender box (male or female) Driver’s License Number: California Driver’s License Number. Height: Your height in feet and inches. Weight: Your weight in pounds. Eye Color: Color of your eyes Hair Color: Color of your hair Place of Birth: Enter your place of birth Social Security Number: Must be included and be correct, unless you have an ITIN. If you have an ITIN, enter this number in the SSN field. Misc. Number: Other identification number Home Address: Your residence address

Level of Service: This has already been preselected for you. You are required to have both DOJ and FBI level of service complete. Please ensure at the time of Live Scan transmission that the Live Scan operator selects both the DOJ and FBI levels of service in their computer system. If FBI is not selected at the time of original transmission, you may be required to have your Live Scan redone at another time and have to repay for the DOJ and FBI levels of services again. The board has been notified by the DOJ that effective 9/1/07, if the FBI level of service is not requested at the time of original transmission both DOJ and FBI levels of service will have to be redone. Any issue of cost for resubmission should be handled at the Live Scan Site level.

Employer: This information is not required.

Take the completed form to your nearest Live Scan site for fingerprint scanning. There are more than 130 Live Scan sites throughout the state. An up-to-date Live Scan site list is on the Department of Justice's (DOJ) Internet web page at https://oag.ca.gov/fingerprints/locations or call your local police or sheriff's department.

Contact the live scan service for hours of operation, an appointment (if necessary), acceptable forms of payment and identification requirements. Be prepared to pay ALL applicable fees (DOJ processing fee of $32, FBI processing fee of $19, and fingerprint scanning service fee) at the time your prints are taken. The live scan fingerprinting service fee varies from about $5 to $20. The cost to electronically submit your fingerprints is determined by the local Live Scan agency and the agency can charge a fee sufficient to recover its costs. The lower portion of the Request for Live Scan Service form must be completed by the live scan operator. The original of the form is retained by the scanning service; the second copy is to be attached to your application and submitted to the board; and the third copy is for your records.

FINGERPRINTING AUTHORITY Section 144(b) of the Business and Professions Code authorizes the Board of Pharmacy to require an applicant for licensure to furnish a full set of fingerprints for purposes of conducting criminal history record checks. Fingerprints are required in order for the DOJ/FBI to conduct background checks for criminal convictions.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICEBCII 8016 (orig. 4/01; rev. 6/09)

REQUEST FOR LIVE SCAN SERVICE

Applicant Submission

ORI (Code assigned by DOJ) Authorized Applicant Type

Type of License/Certification/Permit OR Working Title (Maximum 30 characters - if assigned by DOJ, use exact title assigned)

Contributing Agency Information:

Agency Authorized to Receive Criminal Record Information Mail Code (five-digit code assigned by DOJ)

Street Address or P.O. Box

City State ZIP Code

Contact Name (mandatory for all school submissions)

Contact Telephone Number

Applicant Information: Live Scan Operator – The Board of Pharmacy requires you to enter the applicant’s SSN.

Last Name First Name Middle Initial Suffix

Other Name (AKA or Alias) Last First Suffix

Date of Birth Sex Male Female Driver's License Number

Height Weight Eye Color Hair Color

Place of Birth (State or Country) Social Security Number - MANDATORY

Home Address Street Address or P.O. Box City State ZIP Code

Billing Number

(Agency Billing Number)Misc. Number

(Other Identification Number)

Your Number:OCA Number (Agency Identifying Number)

Level of Service: DOJ FBI

If re-submission, list original ATI number: (Must provide proof of rejection)

Original ATI Number

Employer (Additional response for agencies specified by statute):

Employer Name

Street Address or P.O. Box

City State ZIP Code

Mail Code (five digit code assigned by DOJ

Telephone Number (optional)

Live Scan Transaction Completed By:

Name of Operator Date

Transmitting Agency LSID ATI Number Amount Collected/Billed

ORIGINAL - Live Scan Operator SECOND COPY - Applicant THIRD COPY (if needed) - Requesting Agency